Laserfiche WebLink
Safely and Buildings Division <br />County ,�/� <br />U tNc-il' <br />x` ® <br />201 W. Washington Ave., P.O. Box 7162 <br />g <br />Madison, Wl 53707-7162S— <br />Sanitary Permit Number {to be filled in by Co.} <br />�: Sf <br />�- <br />i7 <br />Sanitary Permit Application <br />ppiica ion <br />State Transaction Number <br />In accordance with SPS 383.21(2), Nis. Adm. Code, submission of this form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />Project Address (if different than mailing address) <br />Purposes in accordance with the Privacy Law, s. I5.04(t)(m). Stats. <br />I. A lication Information —Please Print Ail In€ormation <br />Property Owner's Name <br />de <br />Parcel I <br />/n� <br />eA,4irC` <br />(� <br />Property Owner's %lailing address <br />Property Location <br />ZG y0� T�icamR l��l <br />Govt. Lot <br />y,�,�,Section <br />Gity, State <br />Zip Code Phone <br />Number <br />C,qBCr <br />trcle on <br />T��N; RE or� <br />H. Type of Building (check � <br />YP that <br />g all apply) Lot <br />t <br />IT1 or 2 Family Dwelling —Number of Bedrooms <br />Subdivision Name <br />Block <br />❑ Public/Commercial — Describe Use <br />Cl City of <br />❑ State Owned — Describe Use CSM <br />❑ Village of <br />Number <br />%Totvrtof <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />K Replacement System <br />❑ Treatment/Holdine'fault Replacement Only <br />❑Other Modification to Existing System (explain) <br />Il• <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer ro New, <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. T e of PQi,VTS System/Component/Device: (Check all that apply) <br />9CNon-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound> 24 in. of suitable soil ❑ Mound <24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />11'. Dispersal/Treatment Area Information: <br />Desism 1 lopd) <br />V /Y <br />Design Soil Application Rate(gpdsf) <br />7 <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) System <br />Elevation <br />1 <br />6/ U <br />06 <br />e� <br />� G� �J /✓ / � S <br />VI. Tank Info <br />Capacity in <br />Total <br />;=of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />—' " — <br />� <br />New Tanks RcistingTanks <br />u <br />r <br />Septic or Holding Tank <br />,�ylrO <br />(/�✓ <br />/Mw <br />s/'�(/ <br />i e�j <br />Dosing Cbambcr <br />VII. Responsibility Statement 1, the undersigned, assume responsibility for installation or the PONVTS shown on the attached plats. <br />s Name <br />Pl704 <br />PlIumb s i_naturc <br />MP/`MPRS Number <br />Business Phone Number <br />� �G2— <br />�� <br />.1 �7 <br />—1-t57` 545 —OZO Z. <br />Plumber's Address (Street, City, State, Zip Code)�f/ <br />7ZZv �Lld��da"sl�i gaGl it/1�P135��'l' t++i a 3u� <br />Vill Count- epartment Use Only <br />Approved <br />❑ Disapproved <br />Permit FCC <br />Date Issued <br />Issui g t�gcnt t lure <br />❑ Owner Given Reason for Denial <br />I X. Cpnditions of Approval/Reasons for Disapproval 1 ��(( L0 <br />Ve'Rn' <br />�- p,PR 16 NIS <br />ims rnan u nE fy i lopes insae �TT /V; OU lv <br />Y BURNZONING <br />SBD-6398 (R. 11/11) <br />